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Dr. Andrew Rynne
MD
Dr. Andrew Rynne

Family Physician

Exp 50 years

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I May Just Have Some Sort Of Minor Mood Disorder

Hello. I am a 31 year old male, 6-1, 170lbs and in great shape (work out 3 days per week). I work full-time in a semi-stressful professional environment. About a year or so ago, I was recommended to a psychiatrist because I was having some depression symptoms mainly due to my divorce. The psych put me on seroquel and said that I was bipolar 1 but i was having some unbearable side effects such as restless leg/arm. She tried a series of other anti-depressants over the next few months but I kept having the side effects. She then put me on Remeron (Mirtazapine) (45mg) at bedtime. This was ok for awhile, other than waking up feeling like a zombie and sleeping too much. Over the course of a couple months I began having a nervous, butterfly kind of feeling in my stomach. She couldn t figure out why and then after a couple more visits she said that she misdiagnosed me and said I may just have some sort of minor mood disorder (which I believe everyone has in one way or another). She however prescribed me another 6 refills of the Remeron which last week I thought, why would I keep taking this if I am not bipolar? I tried to cut my dosage in half and was fine for about a week, then all of a sudden starting having really bad anxiety and ultimately a couple of panic attacks at work to the point where I had to go home because I felt like I was going to pass out. I should also mention that I regularly smoke marijuana in the evenings. I decided maybe I tried to ween off of the Remeron too quickly, so I started taking my full dosage again thinking that I would taper off more slowly. I have been on the full 45mg dosage for about a week now and have felt pretty good but now I am afraid if I cut the dosage again the same thing will happen and I don t want to do anything to jeapordize my career by having another attack at work and being so irritable to my co-workers. Do you have any advice/experience with this? I really need some answers but no one seems to be able to provide any. I should also mention I have had full blood work done, complete urine analysis, colonoscopy and endoscopy with nothing but great results except for a bit of gastritis which I am taking 40mg of Prilosec in the morning for.
posted on Sun, 16 Jan 2011
Twitter Mon, 17 Jan 2011 Answered on
Twitter Tue, 25 Jan 2011 Last reviewed on
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Psychiatrist,  's  Response
Hi Joe,

First and most of all, if your diagnosis is really "Bipolar type 1" kind of mood disorder than the psychiatrist is committing professional harakiri by prescribing you only antidepressants. In western countries, your case would be juicy morsel for malpractice/professional negligence lawyers. Please confirm the diagnosis and that you are not on any other medication called "mood stabilisers" like lithium etc to stabilise your mood in addition to the antidepressant.

This is because, in Bipolar depression (manic depression) nobody should be treated for depression with antidepressants initially without trying mood stabilisers first, especially "type 1 bipolar disorder", as antidepressants switch your mood to mania, which SHOULD NOT BE DONE AT ALL.

But from your symptoms description, it seems like you do not have a bipolar depression but unipolar depression (i.e simple depression). Mirtazapine is a correct treatment for that and you seemed to have responded to that as you feel you have improved.

Coming to the fact that you have experienced some withdrawal effects when you cut down the dose means that you may have to do the tapering off more slowly.

BUT and this is a big but, usually Mirtazapine does not have pronounced withdrawal side effects and most of my patients do well tapering it off by 15mg every 1-2 weeks. Also the 1 week gap between the dosage reduction and the onset of anxiety symptoms as well as the nature of anxiety symptoms suggest that they may not have been because of tapering off the Mirtazapine.

AND FINALLY, SMOKING MARIJUANA IS HARMFUL TO THE BODY IN MANY WAYS. pleas refer to this patient leaflet by the royal college of psychiatrists, UK.
http://www.rcpsych.ac.uk/mentalhealthinfo/problems/alcoholanddrugs/cannabis.aspx


Hope this helps.
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Rheumatologist,  Dr. W.P.Singh's  Response
Relax, I want to hear your parents obsevation comments rom them, not from you, you areover concious I presume.I have seen such cases many.I am not Psychiatrist but I will not misguide you.Continue treatment of your best doctor.Good Luck
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Psychiatrist,  Dr. B Raghavendra's  Response
Pardon me, but were you addressing your reply to me Dr Singh?

If so, please check the following evidence based guidelines from NICE of UK, THE professional body which guides doctors practise in UK and whose evidence based guidelines are based on the best accumulated evidence in the world and not based on a single professional's experience.

If not, please accept my apologies.


Guidelines say and I cut paste.....
1.4.3 The management of acute episodes: depressive symptoms

Managing acute depressive symptoms in bipolar disorder has some similarities to managing unipolar depression. However, in bipolar disorder antidepressants carry the risk of 'switching' to manic states, and they may be involved in cycle acceleration (mood destabilisation). There is only a limited role for maintenance treatment with antidepressants in bipolar depression; prophylactic medication has a greater role. When prescribing an antidepressant, an antimanic agent should also be prescribed...............

Treatment of depressive symptoms

Patients not taking antimanic medication

1.4.3.1 A patient who is prescribed antidepressant medication should also be prescribed an antimanic drug.


The url of the guideline is
http://egap.evidence.nhs.uk/CG38/section_1#section_1_4


Hope this helps the patient anyway.
Joe, I stand by my earlier reply.
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  User's Response
JOE's  Response
First off, thank you very much for your intelligent reply. I really do appreciate your insight. Now here are a couple other things that your post brought to my attention. Before I ever went to the psych the first time I never had anywhere near the anxiety I seem to have now when trying to taper off of Remeron. In fact, I never even really noticed any at all. Last year when I was on the Seroquel (200mg I believe) I was having unbearable restless leg/arm syndrome. While slowly weaning off of it I had my first anxiety attack and went to the emergency room because I didn't know what was happening to me (again I was regularly smoking potent marijuana in the evenings). They ran a series of tests and found nothing wrong and attributed it to withdrawal symptoms. The nurse told me Seroquel is a pretty nasty drug. I went to my psych doctor and this is when she put me on the Remeron. Things were fine for awhile and then I began to have severe nervousness all the time and no appetite unless I was "high" on marijuana. The marijuana seemed to be the only thing that gave me an appetite and I knew I needed to eat. Since the latest attempt to ween off Remeron (45mg cut down to 22.5mg) I have not smoked any marijuana (it's been 2 weeks). The nervousness is almost completely gone, I have so much energy and am just in a better mood in general and I am beginning to wonder if long-term, regular use leads to severe anxiety. I really want to try to ween off the med again (45mg) but to be honest am a little scared. I will take your advice and try to ween off more slowly, this time of course there will be no marijuana involved. My main concern is that I had no anxiety and had never had an attack before seeing the psych the first time and now seem to have high anxiety if I try to quit the meds. The attacks just come out of nowhere too. Last time it happened I admit, work was a bit stressful and I suddenly had a chest pain, sweaty palms, face got hot, flushed and tingled a bit. In the past I have always been known for being able to handle stressful situations well. Lastly, could the prolonged anxiety have caused the gastritis?
  User's Response
JOE's  Response
My reply today 1/18/11 is directed at Dr. B Raghavendra, Psychiatrist. The reply from Dr. Singh seems quite ridiculous regarding my parents? I only have my mother left and she didn't want me to start the anti-depressants at all in the first place. She also obviously agrees that I shouldn't smoke marijuana and I haven't in 1 week (I made an error in my reply to Dr. Raghavendra when I said it had been 2 weeks).
Psychiatrist,  Dr. B Raghavendra's  Response
Hi Joe,

Yes, stress MAY cause gastritis...actually there are some ulcers called stress ulcers as well..but i think the forum's GE experts might be the best people to ans this.

I can not guess if the symptoms you had were that of anxiety or panic or cardiac in origin without the results of some test.

So, best would be to do it under a doctor's monitoring and as you say, without marijuana.
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I May Just Have Some Sort Of Minor Mood Disorder

Hi Joe, First and most of all, if your diagnosis is really Bipolar type 1 kind of mood disorder than the psychiatrist is committing professional harakiri by prescribing you only antidepressants. In western countries, your case would be juicy morsel for malpractice/professional negligence lawyers. Please confirm the diagnosis and that you are not on any other medication called mood stabilisers like lithium etc to stabilise your mood in addition to the antidepressant. This is because, in Bipolar depression (manic depression) nobody should be treated for depression with antidepressants initially without trying mood stabilisers first, especially type 1 bipolar disorder , as antidepressants switch your mood to mania, which SHOULD NOT BE DONE AT ALL. But from your symptoms description, it seems like you do not have a bipolar depression but unipolar depression (i.e simple depression). Mirtazapine is a correct treatment for that and you seemed to have responded to that as you feel you have improved. Coming to the fact that you have experienced some withdrawal effects when you cut down the dose means that you may have to do the tapering off more slowly. BUT and this is a big but, usually Mirtazapine does not have pronounced withdrawal side effects and most of my patients do well tapering it off by 15mg every 1-2 weeks. Also the 1 week gap between the dosage reduction and the onset of anxiety symptoms as well as the nature of anxiety symptoms suggest that they may not have been because of tapering off the Mirtazapine. AND FINALLY, SMOKING MARIJUANA IS HARMFUL TO THE BODY IN MANY WAYS. pleas refer to this patient leaflet by the royal college of psychiatrists, UK. http://www.rcpsych.ac.uk/mentalhealthinfo/problems/alcoholanddrugs/cannabis.aspx Hope this helps.